Risk factors for T1 diabetes Symptoms for TI diabetes Risk factors for T2 diabetes Symptoms of T2 diabetes Common in young people Pancreas does not make insulin No insulin production Polyuria- increase urination Polydipsia- increase thirst Polyphagia- increase hunger Weight loss Fatigue Increase frequency of infections Rapid onset Insulin dependent Familial tendency Peak incidence from 10-15 years Most prevalent type of diabetes Increasing in children Obesity, poor diet, and lack of exercise Insulin is produced in insufficient amounts or poorly used Sedentary lifestyle Familial tendency Average age of 50 years Hx of increase BP Fatigue, decrease energy Ovese Recurrent infections Polyuria Polydipsia FBS- >126 T1 meal planning based on individual, usual food intake and balanced with insulin and exercise T2 meal planning goal is to achieve acceptable glucose, lipid, and blood pressure goals Carbohydrates primary source of energy (min 130g/day) Fats provides energy and carries fat-soluble vitamins Protein should contribute 15-20% of total calories consumed Alcohol inhibits gluconeogenesis, can cause severe hypoglycemia if patient taking oral hypoglycemic medications or insulin Carbohydrate counting Each diabeteic bases their insulin doses off of the carbs that they ingest and have different ratios 1 unit of insulin is how many carbs 30 carbs 4 units of insulin is how many carbs 15 carbs How does exercise help with diabetes? When should a person exercise? Delayed exercise induced hypoglycemia What are the 4 M’s of diabetes for patient education? lowers blood glucose level 1 hour after meal and check blood and glucose level before and after exercising May occur several hours after completion of exercise Labs for diagnosing diabetes Hemoglobin A1C Ideal goal for hemoglobin A1C Medication Monitoring Meal planning Motion (exercise) Fasting plasma glucose level >126 mg/dl Random plasma glucose >200 mg/dl + manifestations of diabetes Two hour oral glucose tolerance test level >200 mg/dl using glucose load of 75g A1C of 6.5% or higher Best indicator of glucose level Shows amount of glucose that has been attached to hemoglobin molecule over lifespan of molecule Indicates glucose control for past 90-120 days Determines glycemic levels overtime Used to monitor and make changes in treatments 6.5%-7.0% or less for patient diagnosed with diabetes and being treated Normal A1C level Below 5.7% Prediabetes A1C level 5.7-6.4% Diabetes A1C level 6.5% or above Complications of hyperglycemia Polyuria Glycosuria Polydipsia Weight loss Malaise and fatigue Stressful situations polyuria hyperglycemia acts as osmotic diuretic glycosuria renal threshold for glucose: 180 mg/dl polydipsia thirst from dehydration; from polyuria polyphagia hunger and eats more; since cell cannot utilize glucose Stressful situations Angiopathy body’s response to illness and stress is to produce glucose which can result in hyperglycemia Diabetic Retinopathy Disease of small blood vessels Specific to diabetes Endothelial dysfunction Thickening of the basement membrane in the capillaries and arterioles Seen prior to or with onset of diabetes Lose sensation in areas affected Microvascular damage to the retina due to Chronic hyperglycemia Nephropathy HTN Microaneurysms form Capillary wall week Retinal edema Need annual eye exams Nephropathy Risk factors of Nephropathy Microvascular complication associated with damage that supply glomeruli of kidney Increase risk of infection Increase risk of injury Infection and delayed wound healing High glucose in blood vessels BV become narrow due to scarring Elevated BS level= decreased function of RBC Persistent glycosuria Neuropathy Sensory Neuropathy Foot care of diabteic patients Due to decreased tactile sensation Caution about potential sources of injury to feet Teach patient to inspect inside of shoes for foreign objects Related to hypoglycemia Monitor for s/s of hypoglycemia Teach patient to have simple carbs available Nerve damage due to metabolic disturbances associated with diabetes Autonomic Neuropathy HTN Genetic predisposition Smoking Chronic hyperglycemia Loss of protective sensation in lower extremities Exam feet-avoid injury, proper footwear, proper nail care Can affect nearly all body systems: hypoglycemic unawareness, postural hypotension, painless MI Examine feet daily Wash feet with warm water and mild soap Pat dry, don't rub Keep feet from drying and cracking Extra care with toenail care Nursing management of pt with DM in ambulatory and home care settings Methods to protect the pt with DM from injury and infections Monitor blood glucose Increase BG= increase UO Monitor urine output amount and presence of ketones Monitor IV fluids- insulin therapy- electrolyte imbalance Potassium is needed to move insulin into the cells Assess renal and cardiac status Telemetry monitor because and increase in potassium can affect the heart Assess for neuro changes/consciousness Cardiac monitoring Frequent vital signs (BP, HR, Temp) Reassure patient Hypoglycemia Symptoms of hypoglycemia Treatment of hypoglycemia To influence go shoe wear and protection of feet Don’t keep feet dry or too moisturized Monitor glucose levels before and after exercise too much insulin for available glucose Less than 70 mg/dl Sudden shift and fall of glucose Result of epinephrine Nervousness, irritability, increased heart rate, diaphoresis, impaired mental status TIRED: tachycardia, irritability, restless, excessive hunger, diaphoresis, depression Simple carbohydrate foods; if patient is alert Commercial gels or glucose tabletsalert b/c choking hazard If patients had decreased LOC Diabetic Ketoacidosis Causes of diabetic ketoacidosis Process of diabetic ketoacidosis Clinical manifestations of diabetic ketoacidosis Ketones present Life threatening emergency Gross insulin deficiency predominant problem Most common in T1 Mortality 5-10% Increase calories Too little insulin Stress from physical illnessinfection Undiagnosed DM glucose cannot be used > cellular starvation > breakdown of protein and fats > free fatty acids > ketones Diagnostic test of diabetic ketoacidosis Glucagon IV or IM D50 IV push in acute situation lethargy/weakness Severe dehydration Abdominal pain Anorexia Vomiting kussmaul/labored breathing, high rate Urinary frequency + thirst Breath odor (ketones)- fruity BG >300 mg/dl pH <7.3 HCO3 < 15 mEq/L Positive ketones (blood & urine) Treatment of diabetic ketoacidosis Insulin drip rate Hyperglycemic Hyperosmolar Syndrome (HHS) 0.1u/kg/hr Lab values of HHS ABCs always first priority IV access + NS bolus until BP is stable Insulin drip @ 0.1u/kg/hr Correct electrolyte imbalance Potassium may be initially high due to hemoconcentration- will decrease as fluids are given and insulin drives potassium into cells Life threatening emergency Occurs in patients with type 2 Affects predominantly the elderly Characterized by very high blood glucose levels Without or minimal ketones Mortality is high Occurs in patients that are able to produce some insulin but not enough to prevent hyperglycemia Produces fewer symptoms in early stages- blood sugar can raise quite high before symptoms are seen Blood glucose- >600 mg/dl Increase in serum osmolarity No or very minimal ketones in both blood and urine Medical emergency HHS usually requires greater volumes of fluid replacement Careful to avoid fluid overload Insulin Insulin syringes short acting before meals and long acting once a day Sites of admin for insulin Lipodystrophy Insulin pump Fastest absorption is in the abdomen, then arm, thigh, and buttock bumps dents in skin from repeated injections Sliding Scale Can only be used to give insulin Measured in units not mls Insulin is considered high hazard medication- needs to be double checked by 2 RNs Administered subcutaneously at 45 (for skinny), 60, or 90 degree angle in to subcutaneous tissue- do not aspirate Connected with plastic tube inserted into subcutaneous tissue in abdominal wall Delivers rapid-acting insulin, continuously; 24 hours at a “basal rate” Provides tight glucose control- able to increase amounts during meals, exercise Patient must check blood sugars more often 4-8 times a day Insertion site must be checked frequently Administration set must be changed every 2-3 days: to new sites as well Sometimes referred to as corrective insulin Always use short acting insulin Insulin syringe Oral agents of insulin Metformin MOA Metformin SE ↓ Rate of hepatic glucose production. ↑ Insulin sensitivity. Improves glucose uptake by tissues, especially muscles Glipizide MOA Glipizide SE Sitagliptin SE Diarrhea lactic acidosis. Must be held 1–2 days before IV contrast media given and for 48 hr after Stimulates release of insulin from pancreatic islets. ↓ Glycogenolysis and gluconeogenesis. Enhances cellular sensitivity to insulin Sitagliptin MOA Used for type 2 diabetes Used in combination with each other Many time used with daily glargine (Lantus) or other long acting insulin Elevated sugars covered by rapid or short acting Goal is to control sugar through out day with oral agents and possibly some insulin regimen Weight gain hypoglycemia Enhances activity of incretins. Stimulates release of insulin from pancreatic β-cells. ↓ Hepatic glucose production Pancreatitis allergic reactions Exenatide MOA Exenatide SE Stimulates release of insulin, ↓ glucagon secretion, and slow gastric emptying. ↑ Satiety Liraglutide MOA Liraglutide SE Stimulates release of insulin, ↓ glucagon secretion, and slow gastric emptying. ↑ Satiety Rationale behind carb counting Nausea Vomiting Hypoglycemia Diarrhea headache Nausea Vomiting Hypoglycemia Diarrhea headache Because carbs turn into sugars (glucose) and insulin is needed to break them down Why focus on carbs vs. fats and proteins Fats and proteins are stored more easily in the body through the liver and adipose tissue, while carbs have to have access to cells by insulin to be able to go into the cells Different types of carbs and how they affect glucose level There are carbs simple and complex- simple are broken down in the mouth and these are carbs like starches and simple sugars. While more complex are broken down in the stomach and absorbed in the intestines How to adjust medications: Amiodarone (Cordarone) Medications should be adjusted based on the effect that carbs have on the individual and there insulin ratio as well as the sliding scale (correction dose) Classification: antiarrhythmic clas 3 MOA: prolongs action potential and refractory period. Inhibits adrenergic stimulation. Slows the sinus rate, increases PR and QT interval, and decreases peripheral vascular resistance (vasodilation), suppresses arrhythmias SE of amiodarone Dizziness Fatigue Malaise, corneal microdeposits Bradycardia Hypotension Anorexia Constipation N/V Photosensitivity Hypothyroidism Ataxia involuntary movement Paresthesia peripheral neuropathy poor coordination tremor Furosemide Classification: loop diuretic MOA: inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium- used to mobilize fluid SE of furosemide Spironolactone SE of spironolactone Increased urination thirst, muscle cramps Itching Weakness Dizziness diarrhea Classification: potassium sparing diuretics MOA: acts in the renal distal tubule and collecting ducts decreasing the reabsorption of sodium and decreasing the excretion of potassium Diarrhea Nausea Vomiting leg cramps Headaches Dizziness drowsiness Corticosteroids SE of corticosteroids Doxazosin SE of doxazosin Calcitriol SE of calcitriol Levothyroxine Classification: anti-inflammatory MOA: binding to intracellular receptors which then act to modulate gene transcription in target tissues Glaucoma fluid retention high BP Confusion mood swings delirium Classification: alpha-blocker MOA: Relieves the symptoms of BPH by relaxing the muscles of the bladder and prostate Headache Tiredness Swelling SOB weight gain abnormal vision runny nose Class: Vitamin D analog MOA: Works by helping the body to use more calcium found in foods or supplements and regulating the body’s production of parathyroid Abdominal pain bone pain Apathy BUN and creatinine increased cardiac arrhythmia changes in behavior Constipation decreased libido Class: thyroid hormone MOA: treat hypothyroidism SE of levothyroxine Fatigue increased appetite weight loss heat intolerance Headache Hyperactivity Nervousness Anxiety Tremors sweating
